Recognizing red flags or precaution with a screening process for further treatment is possible already after the first course week in the Maitland Concept! One of the most important things in teaching the Maitland Concept is that the students will be able to transfer what they learned to the clinical ground in their daily practice. At the end of the first course week I always tell my participants, that they now are the specialists of the lumbar spine and “experts” in detecting important precautions or contraindications. One key aspect of the physical examination is an exact neurological examination with testing the sensitivity, muscles innervation and reflexes. And so in Warsaw, at the very start of the second course week, one participant – Tomasz Waraksa-came to me and told a story of one of his patient. In my opinion this is a good story to share with all participants, to highlight the importance of conducting a thorough neurological examination with your patients, when indicated. Here it is:

INTRO 26 years old patient came to the clinic with tingling sensation along his left lower limb. Symptoms occured more than six months earlier without any clear onset. Patient was reffered to the physiotherapist by the orthopaedic specialist with diagnosis of the discopathy on L5/S1 (?) level.

C/O 1. Main problem. Patient’s main problem was a sensation of tingling along the lateral surface of his left lower limb (from hip down to the ankle). Patient also reported, that sometimes he wouldn’t feel his left foot eg. during changing gears on a motorbike. He also reported about problems with strength and precision in his left hand. Symptoms in the foot and hand weren’t constant, but very often appear together. 2. Body chart.

CONCLUSION: PT referred patient to the neurologist. During hospitalization further medical screening was done: – Brain MRI Changes in the right parietal lobe (cortical and subcortical). Right lateral ventricle was enlarged. – Lumbar spine MRI Herniated/disc bulging to the central and left side on the L5-S1 level. – Angio CT R ICA narrowed to 3 mm (L ICA 6 mm). Note: There is no clear diagnosis yet. Specialists suspects thrombophilia/rheumatoid origins/Moyamoya disease.

Additional comment: Even though a lot of cases of spinal pain are described as non-specific and benign it is recommended by most guidelines that screening for serious pathologies are essential steps of your examination process. To assist in this process, red flags screening is recommended for identifying patient with serious medical condition. Referring every patient with a single red flag for further investigation is not practical and would lead to increases costs. Therefore, the decision to refer is much more complex and requires that subjective and objective physical findings are integrated into clinical reasoning process. “Hence the importance of a proper C/O and P/E – connecting facts, thinking in hypothesis categories, and not only relying on the medical diagnosis. It takes courage to tell the patient in the eye: “Well, maybe it would be better if another specialist assessed you as well.” But this is no sign of weakness! In fact, that’s the only fair thing we can do for such patient. This case from a participant of a Maitland course highlights the essential role that all clinicians play in the role of screening for serious pathologies. The interpretation of these clusters of subjective and physical examination findings may lead to refer for further medical investigation.

Special thanks to Tomasz Waraksa/ participant of Level1 in Warsaw Jürg

2 Comments

Renée de Ruijtersagt

05.03.2019

Thank you Jürg and Tomasz for sharing this patient case with us. Sharing these patients’ stories increases our awareness. For everybody who prefers to read in german I would like to refer to the book: Screening in der Physiotherapie: Das Flaggen-System – Warnsignale erkennen. Lüdtke, Grauel & Laube, 2015 Renée

Hi Jürg, thanks for sharing this story. As you clearly state… “One key aspect of the physical examination is a thorough neurological examination with testing the sensitivity, muscles innervation and reflexes.” Many of us will have had similar experiences in their career. A couple of years ago an Italian physiotherapist discovered and aortic aneurysm in one of his patients after a “red flag screening course” in Italy held by Willam Boissonault. It happens “every now and than” that neurological examination reveals a “scenario fit for referral!” A couple of years ago on a course in Italy we picked up a patient ignorant of the fact that he had a cervical myelopathy or another case I have seen (young male, 28 years old) with thoracic myelopathy due to various disc herniations in the thoracic spine… a case which fortunately ended very well! So there is no doubt whatsoever that one important task off any health care provider is to recognize when safe to treat, when”whatchful waiting” is indicated or when fit for referral! If this make us “specialists of the lumbar spine after week 1 or as you phrase it; “At the end of the first course week I always tell my participants, that they now are the specialists of the lumbar spine and “experts” in detecting important precautions or contraindications”.. ??